Provider Demographics
NPI:1467177667
Name:GIBBS, KRESTON TYRELL
Entity Type:Individual
Prefix:
First Name:KRESTON
Middle Name:TYRELL
Last Name:GIBBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:FORDYCE
Mailing Address - State:AR
Mailing Address - Zip Code:71742-7009
Mailing Address - Country:US
Mailing Address - Phone:870-807-3639
Mailing Address - Fax:
Practice Address - Street 1:1122 N PINE ST
Practice Address - Street 2:
Practice Address - City:FORDYCE
Practice Address - State:AR
Practice Address - Zip Code:71742-7009
Practice Address - Country:US
Practice Address - Phone:870-807-3639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care